Prone-Positioning for Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation

Abstract

To determine the characteristics and outcomes of patients pronepositioned during extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and lung CT pattern associated with improved respiratory system static compliance after that intervention. DESIGN:Retrospective, single-center study over 8 years. SETTINGS:Twenty-six bed ICU in a tertiary center. MEASUREMENTS AND MAIN RESULTS:A propensity score-matched analysis compared patients with prone-positioning during extracorporeal membrane oxygenation and those without. An increase of the static compliance greater than or equal to 3 mL/cm H 2 O after 16 hours of prone-positioning defined pronepositioning responders. The primary outcome was the time to successful extracorporeal membrane oxygenation weaning within 90 days of postextracorporeal membrane oxygenation start, with death as a competing risk. Among 298 venovenous extracorporeal membrane oxygenation-treated adults with severe acute respiratory distress syndrome, 64 were prone-positioning extracorporeal membrane oxygenation. Although both propensity score-matched groups had similar extracorporeal membrane oxygenation durations, prone-positioning extracorporeal membrane oxygenation patients' 90-day probability of being weaned-off extracorporeal membrane oxygenation and alive was higher (0.75 vs 0.54, p = 0.03; subdistribution hazard ratio [95% CI], 1.54 [1.05-2.58]) and 90-day mortality was lower (20% vs 42%, p < 0.01) than that for no prone-positioning extracorporeal membrane oxygenation patients. Extracorporeal membrane oxygenation-related complications were comparable for the two groups. Patients without improved static compliance had higher percentages of nonaerated or poorly aerated ventral and medial-ventral lung regions (p = 0.047). CONCLUSIONS:Prone-positioning during venovenous extracorporeal membrane oxygenation was safe and effective and was associated with a higher probability of surviving and being weaned-off extracorporeal membrane oxygenation at 90 days. Patients with greater normally aerated lung tissue in the ventral and medial-ventral regions on quantitative lung CT-scan performed before prone-positioning are more likely to improve their static compliance after that procedure during extracorporeal membrane oxygenation.

Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

“…Four studies [ 9 , 10 , 24 , 30 ] included data for ECMO-related complications comparing the patients according to the use of PP. In six other studies [ 1 , 26 – 28 , 31 , 32 ], these ECMO-related complications were presented without comparisons according to PP use.…”

“…As stated above, obtaining the results of a large interventional trial regarding the survival effect of PP in ECMO patients is very unlikely in the next 5 years. To minimize clinical heterogeneity, we performed a prespecified analysis including only the four studies using a matching process [ 8 – 10 , 26 ]. This additional analysis confirmed the beneficial effect of proning on the survival of ECMO patients.…”

“…1). Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria, including one randomized controlled trial [1] and 12 observational studies [8][9][10][24][25][26][27][28][29][30][31][32], four of which were observational studies [8][9][10]26] with matched controls. All these studies have been published since 2018.…”

“…The PaO 2 / FiO 2 ratio evaluated prior to PP showed a broad distribution (Table 1). The criteria for using PP were specified in three [9,10,25] of the 13 studies. In the four observational studies with matching procedures [8][9][10]26], ECMO patients without PP were similar at baseline to those with PP with respect to age, the severity of illness scores, and several other clinical variables (Table 2).…”

“…A few years ago, some reports indicated that PP in patients receiving ECMO was safe and improved gas exchange [5][6][7]). More recently, PP has been suggested to be associated with an improved survival rate when applied to ARDS patients receiving ECMO [8][9][10]. In the absence of randomized controlled trials, we sought to perform a systematic review and meta-analysis examining the effect of prone positioning on survival in ARDS patients receiving ECMO.…”